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I understand I am responsible for all medical fees during my treatment with Texas Orthopaedic Associates. If surgery is required I assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Texas Orthopaedic Associates. Patient Profile Sheet Name Address First Middle Street City Home Number Work Number Last State Zip Cell Number Email Address Marital Status Date of Birth Age Social Security Number Sex Female or Male Employer s Name Patient Occupation If retired please state so INSURANCE INFORMATION If you have secondary insurance information please advise receptionist Name of Insurance Carrier Insured s Date of Birth Soc. Sec. No. of Insured Relationship to the Insured Self Spouse Child Other Name of Insured s Employer City State Zip Code Telephone Number Policy Number Referring or Primary Care Doctor Group Number How were you referred Next of Kin/Emergency Contact Name and Address Date of Injury I authorize Texas Orthopaedic Associates to release medical information that may be necessary to request reimbursement by my insurance company to whom I have submitted claims. This assignment will remain in effect until revoked by me in writing. A photocopy or assignment is to be considered as valid as an original* I understand any overpayment on my account will be promptly refunded* Disclosure of Interest Drs Paschal Montgomery Thornton and Payne have an ownership interest in Texas Institute for Surgery at Presbyterian Hospital of Dallas and as a result may financially benefit from the referral of services to the hospital in the form of increased dividends or distributions. You have the option of using an alternative health care facility. Please let us know if you have any concerns regarding the financial relationship between Dr s Paschal Montgomery Thornton and Payne and Texas Institute for Surgery at Presbyterian Hospital of Dallas. This assignment will remain in effect until revoked by me in writing. A photocopy or assignment is to be considered as valid as an original* I understand any overpayment on my account will be promptly refunded* Disclosure of Interest Drs Paschal Montgomery Thornton and Payne have an ownership interest in Texas Institute for Surgery at Presbyterian Hospital of Dallas and as a result may financially benefit from the referral of services to the hospital in the form of increased dividends or distributions. You have the option of using an alternative health care facility. Please let us know if you have any concerns regarding the financial relationship between Dr s Paschal Montgomery Thornton and Payne and Texas Institute for Surgery at Presbyterian Hospital of Dallas.

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